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Surgical site infection remains an unsolved issue in orthopaedic surgery
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Among the most severe and frustrating complications orthopaedic surgeons encounter is when a well-performed and otherwise successful surgical treatment to fix a fracture, insert a joint replacement implant or perform a spinal decompression ends up with an early surgical site infection.
Whether the patient is ready for discharge from the hospital or just has been discharged, the patient who develops a surgical site infection (SSI) is usually faced with more surgery, a longer hospital stay, long-term antibiotic treatment and disability and morbidity. In some cases of SSI, our patients have lifelong memories of “that day in surgery” that caused them so many ongoing problems.
Despite all the technological advances today, we still do not know much about SSI. It remains a major issue. Groups like the World Health Organization have started programs to stop these kinds of infections from occurring, but SSI is still a major problem for patients and surgeons with implications for health care economics, as well.
Much has been written about the frequency and prevention of SSI, which is almost always a topic on the program of orthopaedic meetings, where it is a hotly debated issue. Once again, I cannot help but wonder why we, for the most part, are unsuccessful in eliminating SSI or limiting its extent.
Change your practices
In my opinion, three areas need discussion. First, SSI is not due a single factor. It is probably multifactorial, since scientifically, to prove the effect of a single factor, you must control all the other factors and some of them may be unknown in this situation. Therefore, this makes the scientifically sound prevention of SSI highly complicated and nearly impossible. Most orthopaedic surgeons know this from their daily practices since we all face SSIs and frequently discuss the reasons. In my department, we have not been able to find one clear-cut reason for any of our patients’ infections.
When you encounter a few infection cases in a short period of time, it is tempting to change your practices drastically. For some reason, this seems to help resolve the infection, but it does not help beyond that since we do not know exactly which step resolved the SSI and more importantly, why.
The second reason we are unsuccessful in the elimination of SSI is because this part of our work is not attractive to study. Perhaps we think that focusing on this area will impact our professionalism and possibly even our income. But, I believe we must take just as much ownership and responsibility for SSIs — and their prevention — as we do for the surgery we perform. This may involve leading research that is focused on the prevention of SSIs and other efforts.
SSI prevention: Your priority
Third, a focus on this topic is needed right now within the orthopaedic community and we can start on that today. Every orthopaedic congress should have infection on the agenda prominently to ensure the topic is discussed and that there are sessions in which presenters and attendees can report their observations on SSIs and which treatments have been most successful. Such information will assist us in better understanding the clinical aspects of SSI and its prevention.
Even in my hip replacement practice in Denmark, we must all ask ourselves what we can do right now, where we work, to stop the increase in SSI. A good place to begin is an organized internal audit of actual or suspected musculoskeletal infections. Doing that might help us and our infectious disease colleagues better under why a particular SSI occurred. That might lead to a formal discussion of anti-infection practices at the hospital, including whether traffic in the operating room should be limited to reduce infection rates.
I encourage you to take a small step right now, such as during your next surgical case or by discussing the ideas I just mentioned with your operating room staff to start reducing orthopaedic SSIs. Keeping the rates of this devastating complication low requires all of us to focus on the problem and take one step at a time.
- For more information:
- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.